Taking Healthcare to School

by Hope Vanderberg

A typical day for Rocky S. Thomas, CPNP, goes something like this: Get up at 5 AM, work out, jump in the shower by 6, get dressed, jump in the car, and drive from her home in Winter Park, Florida, just outside Orlando, to Colonial High School on the far east fringe of Orlando. Arrive at 7:30am and see 30 or 40 kids -- by noon. Jump back into the car, slip a Harry Potter audiobook into the tape deck, and drive 45 minutes to the Apopka Children's Health Center to see more kids from 1 PM until 7 PM, 4 afternoons a week, and to teach at the nurse practitioner program at the University of Florida - Orlando extension campus 1 afternoon a week. "Then I come home and stare at the walls," she says.

This is hard to believe -- even in a recent postwork evening interview, Thomas is hard to keep up with. She weaves through the traffic of her thoughts with effortless speed, rattling off the various projects and people she works with, to tell the story of how the school-based health program that she runs got started, and how it has grown.

Adolescents and Healthcare

The students that Thomas treats every day are a forgotten segment of the pediatric population. They are poor, many are recent immigrants, and they are adolescents. According to a 1994 study by JD Klein,[1] adolescents have the lowest utilization of healthcare services of any age group, and are the least likely to seek care through traditional office-based settings. They are also more likely to be uninsured than any other age group. For adolescents living below the poverty level, as many in Thomas's area are (and as 17% of the nation's adolescents were in 1998, according to a Centers for Disease Control and Prevention (CDC) report[2]), 1 of every 3 has no health insurance.[3] Many more are underinsured, with insurance that doesn't include preventive care, counseling, or substance abuse treatment.[1] Yet this is the population most in need of healthcare: poverty is associated with an increased risk of chronic health problems,[4] and adolescents from any background face a number of unique health issues.

According to the CDC, the most pressing health issues for adolescents include violent crimes, injuries, sexually transmitted diseases (STDs), pregnancy, and suicide (seriously considered or attempted by one quarter of US high school girls and 14% of high school boys in 1999).[2] "Ironically, they are at a very vulnerable age and have few 'safe' sources of confidentiality, education, and counseling," Thomas says. She has not forgotten this population, though one wonders how it is that she hasn't forgotten her own name, considering the number of hats she wears on any given day in her work to provide and promote school-based healthcare.

Getting Started

Thomas is used to wearing many hats. Before she went into nursing, she was a teaching tennis pro and later a high school English teacher. She then became a nurse and worked for 13 years in pediatric critical care before going back to school for a year to become a nurse practitioner. In many ways, these earlier experiences were preparation for her current work. As a teaching tennis pro, she recalls, she introduced impoverished children to a traditionally "rich man's sport" and she marveled at how quickly some of her students picked it up, despite never having seen a tennis racket before. It was simply a question of giving the children access to the game, a lesson she carries with her today in the world of healthcare. As for her teaching experience, its usefulness in her current career extends beyond a knack for navigating school systems in her job at a school clinic. It also certainly contributes to her third job, at the University of Florida -- upon graduating from her nurse practitioner program in 1995, she was immediately hired to teach this program.

In 1995, while Thomas was a student, her preceptors, Jonathan Schneider, DO, and Penelope Tokarski, MD, of the Nemours Children's Clinic in Orlando, were approached by a social worker from a predominantly African American high school in nearby Eatonville. The social worker had noted the students' need for medical care, screening, and education, and suggested that they start a clinic there. For Dr. Schneider and Dr. Tokarski, this was an opportunity for the students in their residency program to fulfill their required adolescent rotation. This rotation had always been challenging, as many adolescents steer clear of doctors' offices. So, the doctors went to them. Dr. Schneider and Dr. Tokarski began volunteering, and Thomas went with them. They started a clinic in a community service center in Eatonville, adjacent to the school. The Orange County School Board funds these centers on a number of school campuses in poor, underserved areas, and they house a variety of services, including the clinic.

At first, they went in a couple of days a week, with a handful of residents in tow, and saw perhaps 4 or 5 patients a day. They provided whatever was needed -- screenings, physicals, treatment, and education. They also traveled to other schools, on request, to conduct sports physicals. Word spread, and eventually students at Eatonville began pouring in, and so did the calls from other schools. In 1996, a nonprofit company called Community Health Centers began running the program. Budget money from another community service center was used to hire another pediatric nurse practitioner and open a second clinic in Orange County, and then a third.

Despite the program's success, in 1998 the Medical Director of Community Health Centers decided not to continue it. Thomas, who by now had graduated and was working mornings for the program at Colonial High School and dedicating afternoons to a children's health center in Apopka (separate from the program), refused to let the program go. She and the 2 other nurse practitioners (Pam Flaherty, PNP, who joined the program in 1996, and Linda Gilliland, who has since gone on to other ventures) put in a bid to take it over, and the school board awarded them the contract.

Thomas was now President, and Flaherty, Vice President, of the company officially known as Healthcare Providers of Florida -- a lofty name, perhaps, for a company that provided healthcare to a total of 3 clinics in Orange County, but also an indicator of their vision and determination to expand. And they have expanded, doubling to a total of 6 schools (2 high schools, 1 middle school, and 3 elementary schools) and counting. In addition to running the program, Thomas has also been busy cultivating a yearly crop of new nurse practitioners at the university, the cream of which she hires to work at new clinics.

Growing Pains

About 5000 new students move to Florida every year. Families from all over the nation and from numerous third-world countries, hoping for a better life, transplant themselves in the land where the sun always shines and the tourist industry is always hiring. But even in the
"Sunshine State," good health and access to good healthcare are no guarantees. Newly arrived parents may find work, but they cannot afford to miss a day of it to take their young children to the doctor, nor do they have insurance to pay for it. And older children face their own set of difficulties, as Thomas has learned.

In addition to diagnosing and treating a surprising amount of pathology (Thomas says that many adolescents walk in with conditions such as asthma or even congenital heart defects that were never diagnosed before their high school entry physical), she and her coworkers often end up being counselors. "A great percentage of their physical ailments are related to their psychosocial life," Thomas says of the students. Many of the students at Colonial High School are not just wrestling with the usual adolescent issues. They are also struggling with a new culture, a new language (most are Puerto Rican or South American), and often, a great deal of responsibility at home. Many work -- one student was sent to Thomas by a teacher who was concerned because the girl kept falling asleep during class. Thomas learned that the student was working 40 hours a week after school to help pay the rent for the apartment she shared with her aunt. Some have been kicked out of their house, others come bearing belt scars. Many suffer from anxiety. One girl came in and handed Thomas some of her poetry. She asked her to edit it, as Thomas had once been an English teacher. Instead, Thomas ended up taking the girl to the hospital -- the poem turned out to be a suicide note.

Because students view the nurse practitioners as safe sources of information who will keep their conversations confidential, they often come to the clinic simply to ask questions. The most frequently discussed topics are sex, STDs, and pregnancy. Education regarding these issues is sorely needed, Thomas says.

One girl came in and told Thomas that she thought she was pregnant. She had last had sex on August 15. "And when did you last have your period?" Thomas asked. "September 1," the girl replied. Trying to determine where exactly the girl's confusion lay, she asked her why she thought she was pregnant, and the girl explained, "Oh, it's my boyfriend who thinks I'm pregnant. Because he's been throwing up." Thomas has had this exact conversation with not 1 but 3 girls, in 2 different schools. The first girl, age 17, already had 2 children.

Overcoming Obstacles

In her first year, Thomas saw about 300 students. Now she sees more than that in a month. All together, the 6 pediatric nurse practitioners currently see about 17,000 students each year, nearly 6 times the number of students treated in the first year of the program.

The program has created a win-win situation for everyone involved -- the students, the schools, and the healthcare system. The students get free healthcare simply by enrolling in the program with their parents' permission. The schools benefit by keeping attendance up -- students can be treated on site and sent back to class, instead of being sent home unnecessarily by well-meaning teachers who often fear the worst when a student isn't feeling well.

Having the nurse practitioners there to provide reassurance to the teachers and the students is key. "Every eye that's pink isn't pinkeye," Flaherty says. The healthcare system benefits economically, by providing care to children whose entry into the healthcare system would otherwise be via the Emergency Room. And of course, residents benefit by fulfilling their adolescent rotation -- Dr. Schneider (who is now the company's Medical Director) and Dr. Tokarski still send their residents to the clinics.

Nevertheless, funding continues to be the biggest obstacle for Healthcare Providers of Florida. In 1997, Florida's $11.3 million settlement with the tobacco industry ensured that the program would have state funding for a long time to come (the money is being used to fund children's health programs and antismoking education). But they receive the same amount of money each year, despite the program's expansion and increasing expenses, so they have had to find other sources of funding as well.

They get some additional money through public and private grants. And as of August 17, through an expansion of the Florida Medicaid certified school match program, their clinics have been deemed eligible to bill Medicaid for their services, starting in the next month or so. They will be reimbursed about $4 or $5 per student. According to Flaherty, the Medicaid money will be put in a separate fund for a year and allowed to grow. Hopefully there will be enough to fund another position, and therefore another clinic, she says.

Getting Involved

For those who want to get involved in school-based healthcare, Thomas has 2 words of advice: "Start small." Try volunteering 1 evening a week. One way to get a foot in the door, she says, is by offering to do sports physicals or be a team physician for a school. Or volunteer to do physicals for the Special Olympics. And don't get discouraged by lack of funding.

"Even though funding is a problem every year, we somehow press on regardless," Thomas says. "We are all so fortunate in this country, and those in the medical field get a dose of perspective on a daily basis." For Thomas and her coworkers, providing healthcare to youth who don't have access to it isn't simply a matter of goodwill, it's an obligation. Thomas says, "We owe a debt and we can pay -- or at least make a dent in it."

Resources

The National Assembly on School-Based Health Care
Promotes school-based healthcare and provides community, state, and national advocacy, information and knowledge exchange, networking opportunities, and technical assistance. Includes links to potential funding sources and existing programs, sorted by state.

The Center for Health and Health Care in Schools
Information on statistics, program development, and state and national policies from this nonpartisan policy and program resource center located at The George Washington University School of Public Health and Health Services.

Healthy Schools, Healthy Communities Program
The Bureau of Primary Health Care's "Healthy Schools, Healthy Communities" is the first Federal program to support the creation of school-based health centers.

Health, United States, 2000 With Adolescent Health Chartbook. National Center for Health Statistics, Centers for Disease Control and Prevention, US Department of Health and Human Services. Hyattsville, Maryland: 2000. Available as a PDF file at: http://www.cdc.gov/nchs/products/pubs/pubd/hus/hus.htm